Eating Disorders Process Addiction

Eating DisordersEating Disorders

Leigh Falls Holman, PhD, LPC-S, RPTS, NCC

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Screening and Assessment Screening and Assessment Screening should occur with any individual

indicating issues with body weight, body shape, or attitudes towards eating that appear to be disordered

Suicidality should be assessed at the same time due to elevated risk in individuals with eating disorders

Depression and anxiety symptoms should be assessed

SCOFF ScreenSCOFF ScreenDo you make yourself Sick because you feel

uncomfortably full?Do you worry you have lost Control over how

much you eat?Have you recently lost more than One stone in a

3 month period?Do you believe yourself to be Fat when others

say you are too thin?Would you say that Food dominates your life?*One point for every ‘yes’ **Score of ≥ 2 indicates a likely case of anorexia or

bulimiaMorgan, J. Reid, F. , (1999). The SCOFF questionnaire: Assessment of a new screening tool for eating disorders.

British Medical Journal. 319:1467. doi: http://dx.doi.org/10.1136/bmj.319.7223.1467http://en.wikipedia.org/wiki/SCOFF_questionnaire

ACORN Eating Disorder InventoryACORN Eating Disorder Inventory

http://foodaddictioninstitute.org/Publications/Assessment-Acorn-Eating-Disorder-Inventory.pdf

Eating Attitudes TestEating Attitudes Test http://psychcentral.com/quizzes/eat.htm 40 item version – EAT-40 (Garner & Garfinkel, 1979) 26 item version - EAT-26 (Garner, Olmsted, Bohr, &

Garfinkel, 1982) 12 item version – EAT-12 (Lavik, Clausen, & Pedersen,

1991). Children’s Eating Attitudes Test (ChEAT; Maloney et al.,

1989) Sensitivity .77; specificity .95 & .94; Positive predictive

values .82 & .79; negative predictive values .93 & .94 3 factors (across cultures and gender and age):◦ Dieting and purging behaviors◦ Binging and food preoccupation◦ Social pressures to eat

Eating Attitudes Test (Garner & Garfinkel, 1979)Eating Attitudes Test (Garner & Garfinkel, 1979)EAT-26 Self TestEAT-26 Self Test

26 Item self-report inventory: http://eat-26.com/Form/

40 item EAT-40 http://eat-26.com/Form/index.php?test_type=eat40

Good concurrent validity (Williamson, Anderson, Jackman, & Jackson, 1995).

Simple and QuickMay be given repeatedly to gauge

progress in treatment

Bulimia Test-Revised (BULIT-R)Bulimia Test-Revised (BULIT-R)(Thelen, Farmer, Wonderlich, & Smith, 1991)(Thelen, Farmer, Wonderlich, & Smith, 1991)28 item questionnaire based on DSM II-R R = .99Can discriminate BN from ANCutoff – 104Brief, easy to score, well-validated ◦ Internal Consistency: (Adult women: r = .92-.98; Girls:

r = .9; Boys: r = .88)◦ Test-Retest over 2 month period: .95◦ High concurrent and convergent validity in adult and

adolescent femalesScreening or progress in treatment

Eating Disorder Examination (EDE)Eating Disorder Examination (EDE)Cooper & Fairburn, 1987; Fairburn & Cooper, 1993)Cooper & Fairburn, 1987; Fairburn & Cooper, 1993)

2 behavioral indices◦ Overeating◦ Methods of extreme weight control

4 Subscales: ◦ Restraint◦ Eating concern◦ Shape concern◦ Weight concern

Investigator-based interview Inter-rater reliability (Cooper, Fairburn, 1987; Wilson & Smith,

1989); Test-Retest (Rizvi, Peterson, Crow, & Agras, 2000); & Internal consistency (Cooper, Cooper, & Fairburn, 1989).

Commonly used in treatment outcome studies Requires training to use

Interview for the Diagnosis of Eating Disorders-IV (IDED-IV)Interview for the Diagnosis of Eating Disorders-IV (IDED-IV)(Kutlesic, Williamson, Gleaves, Barbin, & Murphy-Eberenz, (Kutlesic, Williamson, Gleaves, Barbin, & Murphy-Eberenz, 1998)1998)

Semi-structured interviewDifferential Diagnosis DSM-IV AN, BN, & BEDGood reliability and validity (Kutlesic et al., 1998)Strength: client responses are rated on severity scales

directly related to DSM-IV criteriaScore of 3 or above on a 1-5 scale is diagnosticFollowing interview, rater completes a diagnostic

checklist using the severity ratings that leads directly to differential diagnosis according to DSM-IV criteria.

Eating Disorder Inventory-3 Eating Disorder Inventory-3 (Garner, 1991)(Garner, 1991) Self-report inventory Assess symptoms of AN and BN Provides standardized assessment of severity of symptoms – not

diagnostic Can provide useful background info Validated with both clinical and non-clinical groups across different

cultures, both adolescents and adults Translated into Arabic, Bulgarian, Chinese, Dutch, German,

Hebrew, Portuguese, Spanish, & Swedish Moderate to high internal consistency (r = .70-.93) for subscales 91 questions, 11 subscales◦ 3 assess attitudes and behaviors concerning eating, weight, and shape◦ Other 8 assess: psychological disorders, Ineffectiveness, perfectionism,

interpersonal distrust, introspective Awareness, Maturity Fears, Ascetics, Impulse Regulation, and Social Insecurity

Figure 9.2: Medical Effects of Figure 9.2: Medical Effects of AnorexiaAnorexia

Figure 9.3: Diagnostic Crossover Figure 9.3: Diagnostic Crossover in Eating Disordersin Eating Disorders

DiagnosisDiagnosisDSM 5 Chapter: Feeding and Eating

DisordersClinical Features:◦ “persistent disturbance of eating or eating-

related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, p. 329)

Similarities to Substance Addictions:Similarities to Substance Addictions:“Some individuals with disorders described in this

chapter report eating-related symptoms resembling those typically endorsed by individuals with substance use disorders, such as craving and patterns of compulsive use” (APA, p. 329).

“This resemblance may reflect the involvement of the same neural systems, including those implicated in regulatory self-control and reward, in both groups of disorders. However, the relative contributions of shared and distinct factors remain insufficiently understood” (APA, p. 329).

Anorexia Nervosa (307.1)Anorexia Nervosa (307.1)(Criterion A) (Criterion A) Restriction of energy intake relative to

requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.

Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

If you weight the client in the office, then make certain shoes are off, overcoats/sweaters are off, and pockets are emptied prior to weighing.

Anorexia Nervosa (Criterion B)Anorexia Nervosa (Criterion B)Diagnostic Features:◦ Persistent energy intake restriction◦ Intense fear of gaining weight or of becoming

fat, or persistent behavior that interferes with weight gain◦ Disturbance in self-perceived weight or shape

Anorexia Nervosa (Criterion C)Anorexia Nervosa (Criterion C)Disturbance in the way in which one’s

body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Anorexia Nervosa (Coding)Anorexia Nervosa (Coding)Regardless of code, specify which type.Crossover between subtypes over the course of the

disorder is not uncommon. Therefore, subtype describes current symptoms only.

The ICD-9 Code is 307.1 which is assigned regardless of the subtype.

The ICD-10 CM code depends on the subtype:◦ Restricting Type (F50.01): During the last 3 months the

individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or misuse of laxatives, diuretics or enemas).◦ Binge-Eating/Purging Type (F50.02): During the last 3

months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or misuse of laxatives, diuretics or enemas).

Anorexia Nervosa (Specifiers)Anorexia Nervosa (Specifiers) Remission, if applicable: After full criteria previously met, ◦ Partial Remission: Criterion A (low body weight) has not

been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.◦ Full Remission: None of the criteria have been met for a

sustained period of time. Current Severity: (adults – based on BMI and children and

adolescents based on BMI percentile). Severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.◦ Mild: BMI ≥ 17 kg/m2 ◦ Moderate: BMI 16-16.99 Kg/m2◦ Severe: BMI 15-15.99 kg/m2◦ Extreme: BMI ≤ 15 kg/m2

Anorexia Nervosa: Anorexia Nervosa: Associated FeaturesAssociated Features Some health effects may be reversed with nutritional rehabilitation,

but some are not completely reversible, such as bone mineral density

Comorbidity:◦ Depression – Suicide risk is elevated (12/100,000/year)◦ Biploar Disorder◦ Anxiety Disorders◦ Obsessive Compulsive features (both related and unrelated to food –

restricting type more likely to have OCD)◦ Substance Addictions (more common with binge/purge type)◦ Hoarding

Semi-starvation may be associated with:◦ Problems with major organs (heart)◦ Physiological disturbance (amenorrhea)◦ Vital sign abnormalities◦ May or may not have lab abnormalities

Anorexia NervosaAnorexia Nervosa More females than males 10:1 12 month prevalence for females is approximately .4% Usually begins during adolescence or young adulthood, but

rarely before puberty or after 40◦ Younger: may manifest atypical features, including denying ‘fear

of fat.’ ◦ Older: more likely to have a longer duration of the illness &

clinical presentation may include more signs and symptoms of long-standing disorder

Course and outcome are highly variable◦ Course: Onset often triggered by stressful life event◦ Outcomes:

Some individuals recover fully after a single episode of AN. However, some have fluctuating or chronic problems with AN over their lives.

Hospitalization may be required to restore weight and to address medical complications. Remission rates lower for these folks.

Most experience remission within 5 years of presentation (p. 342) Mortality rate 5% per decade due most often to medical complications

or suicide.

Anorexia Nervosa: Anorexia Nervosa: Risk & Prognostic Factors Risk & Prognostic Factors Temperamental:◦ “individuals who develop anxiety disorders or display obsessional traits

in childhood are at an increased risk of developing AN Environmental:◦ “Historical and cross-cultural variability in the prevalence of AN

supports its association with cultures and settings in which thinness is valued” (APA, p. 342).

◦ “Avocations that encourage thinness, such as modeling and elite athletics, are also associated with increased risk. (APA, p. 342).

Genetic and Physiological:◦ Increase risk in 1st degree biological relatives◦ Increased risk of bipolar and depressive disorders of 1st degree

relatives, particularly binge/purge type◦ Monozygotic twins higher than dizygotic twins◦ Brain abnormalities using fMRI identified (but this may result from

malnutrition vs. primary abnormalities)

Anorexia Nervosa: Anorexia Nervosa: Diagnostic MarkersDiagnostic MarkersHematologySerum ChemistryEndocrineElectrocardiographyBone MassElectroencephalographyResting Energy ExpenditurePhysical Signs and Symptoms

Anorexia Nervosa: Anorexia Nervosa: Functional ConsequencesFunctional ConsequencesMay function socially and professionally

or may notSocial isolationFailure to fulfill academic or career

potential

Anorexia Nervosa: Anorexia Nervosa: Differential DiagnosisDifferential DiagnosisMedical Conditions such as gastrointestinal

disease, hyperthyroidism, occult malignancies, and AIDS.

Major Depressive DisorderSchizophreniaSubstance Use DisordersSocial Anxiety Disorder (Social phobia), OCD,

and Body Dysmorphic DisorderBulimia NervosaAvoidant/restrictive Food Intake Disorder

*What is the primary cause of the symptom?

Bulimia Nervosa (307.51, F50.2)Bulimia Nervosa (307.51, F50.2)Criterion ACriterion ARecurrent episodes of binge eating. An

episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within

any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Bulimia NervosaBulimia NervosaBinging Triggers◦ Interpersonal stressors◦ Dietary restraint◦ Negative feelings related to body weight,

body shape, and food◦ boredom

Consequences◦ Negative self-evaluation◦ Dysphoria

Bulimia Nervosa (Criteria, cont.) Bulimia Nervosa (Criteria, cont.) B. Recurrent inappropriate compensatory behaviors in order

to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Bulimia Nervosa (Specifiers)Bulimia Nervosa (Specifiers) Remission: After full criteria for BN were previously met, ◦ In partial remission: Some, but not all, of the criteria have been met for

a sustained period of time.◦ In full remission: None of the criteria have been met for a sustained

period of time. Severity (current): the minimum level of severity is based on the

frequency of inappropriate compensatory behaviors. It may be increased to reflect other symptoms and the degree of functional disability.◦ Mild: An average of 1-3 episodes per week of inappropriate

compensatory behavior◦ Moderate: An average of 4-7 episodes per week of inappropriate

compensatory behavior◦ Severe: An average of 8-13 episodes per week of inappropriate

compensatory behavior◦ Extreme: An average of 14 or more episodes per week of

inappropriate compensatory behavior

Bulimia Nervosa:Bulimia Nervosa:Diagnostic FeaturesDiagnostic FeaturesRecurrent episodes of binge eatingRecurrent inappropriate compensatory

behaviors to prevent weight gainSelf-evaluation unduly influenced by body

shape and weightMust occur 1x/week for 3 months on

average

Bulimia Nervosa:Bulimia Nervosa:Associated Features Associated Features Typically normal weight or overweight (BMI ≥ 18.5

and ≤ 30 in adults).Uncommon among obese individualsBetween binges – restrict caloric intakeMenstrual irregularity Fluid and electrolyte disturbances due to purgingRare but potentially fatal complications including

esophageal tears, gastric rupture, and cardiac arrhythmias.

Serious cardiac and skeletal myopathies may happen due to vomiting

Abuse of laxatives may lead to dependence Gastrointestinal symptoms and rectal prolapse

Bulimia NervosaBulimia Nervosa Prevalence:◦ 12 month prevalence among young females is 1%-1.5%.◦ Prevalence is highest among young adults – peaks in older adolescence and young

adulthood.◦ More common in females than males 10:1.

Course and Outcome:◦ Onset before puberty or after 40 is uncommon.◦ Frequently begins during or after an attempt at dieting. ◦ Multiple stressful life events can precede onset◦ Disturbed eating behavior persists for at least several years in most clinical samples –

may be chronic or intermittent◦ Symptoms of many diminish over time without treatment, although treatment clearly

impacts outcome◦ Remission longer than 1 year associated with better outcome◦ Significantly elevated risk for mortality (all-cause and suicide) Crude mortality rate –

2% per decade.◦ Diagnostic cross-over to AN 10%-15% - often have multiple cross-overs between AN

and BN◦ May cross-over to BED

Bulimia Nervosa: Bulimia Nervosa: Risk & Prognostic FeaturesRisk & Prognostic Features Temperamental:◦ Weight concerns, low self-esteem, depressive symptoms, social

anxiety disorder, and overanxious disorder of childhood are associated with increased risk for the development of BN.

Environmental:◦ Internalization of a thin body ideal increases risk. Childhood

sexual/physical abuse are at an increased risk. Genetic and Physiological:◦ Childhood obesity and early pubertal maturation increase risk. ◦ Familial transmission of BN may be present, as well as genetic

vulnerabilities for BN Course Modifiers:◦ Severity of psychiatric comorbidity predicts worse long-term

outcome of BN

BN: Functional ConsequencesBN: Functional ConsequencesSevere role impairmentSocial-life domain most likely to be

adversely affectedSuicide risk elevated

BN: Differential DiagnosisBN: Differential DiagnosisAnorexia Nervosa, Binge-eating/purging

type Binge Eating DisorderKleine-Levin Syndrome: disturbed eating

does not include over-concern about body shape or weight

Major Depressive Disorder, with Atypical Features

Borderline Personality Disorder: impulsive behavior in BPD may result in BN symptoms

BN ComorbidityBN ComorbidityMost have one other mental health issueMany have multiple comorbiditiesIncreased frequency of:◦ Depressive symptoms, bipolar & depressive

disorders◦ Anxiety symptoms (social situations) or

anxiety disorders◦ Substance Use Disorders (30% lifetime

prevalence among BN clients)

(307.51/F50.8)Binge Eating Disorder (307.51/F50.8)Binge Eating Disorder

DSM IV TR: ◦ Appendix B: Criteria Sets and Axes Provided for Further Study

◦ Diagnosed as ED NOS DSM 5:◦ Added BED to Feeding and Eating Disorders chapter

◦ Recognition that a large percentage of ED NOS diagnoses could be attributed to BED

◦ More severe and less common than overeating and associated with significant physical and psychological problems

◦ Criteria A-E will must be met

Binge Eating Disorder (Criterion A)Binge Eating Disorder (Criterion A)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1.Eating, in a discrete period of time (w/in 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.

2.A sense of lack of control over eating during the episode (e.g. feeling that one cannot stop eating or control what or how much one is eating).

Binge Eating Disorder (Criterion B)Binge Eating Disorder (Criterion B)

B. The binge-eating episodes are associated with 3/more of the following:

1. Eating much more rapidly than normal.2. Eating until feeling uncomfortably full.3. Eating large amounts of food when not feeling

physically hungry.4. Eating alone because of feeling embarrassed by how

much one is eating.5. Feeling disgusted with oneself, depressed or very

guilty afterward.

Binge Eating Disorder (Criteria, Cont.)Binge Eating Disorder (Criteria, Cont.)

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Binge Eating Disorder Specifiers (p. 350)Binge Eating Disorder Specifiers (p. 350)

Partial/Full Remission After full criteria for BED were met, binge-eating disorder were previously met, ◦Partial: Binge eating occurs at an average frequency of less than one episode per week for a sustained period of time.

◦Full: none of the criteria have been met for a sustained period of time.

Severity◦Mild: 1-3 episodes of binge eating each week◦Moderate: 4-7 episodes of binge eating each week◦Severe: 8-13 episodes of binge eating each week◦Extreme: 14/more episodes of binge eating each week

BED: Associated FeaturesBED: Associated Features

Prevalence: (p. 351)◦ 12 month prevalence among adults:

Female: 1.6% Males: .8%

Development & Course : (p. 352)◦ Binge eating usually precedes BED whereas dieting

usually precedes onset of binge eating in bulimia nervosa)◦ Treatment seeking BED clients are usually older than

AN/BN treatment seeking clients◦ Course: persistent, similar to BN in severity & duration

Risk and Prognostic Factors: Indication of Genetic predisposition

BED: Associated FeaturesBED: Associated Features

Culture-Related Diagnostic Issues◦ Similar across industrialized countries◦ Similar across ethnicities

Functional Consequences◦ Social role adjustment problems◦ Impaired health-related quality of life & life

satisfaction◦ Increased medical morbidity & mortality◦ Increased health care utilization compared

with BMI-matched control subjects

BED: Associated FeaturesBED: Associated Features

Differential Diagnosis◦ Bulimia Nervosa:

BED doesn’t have recurrent compensatory (purge/exercise) behavior BED consistently higher rates of improvement than BN◦ Obesity:

BED higher rates of overvaluation of body weight and shape BED rates of psychiatric comorbidity are significantly higher BED better outcomes◦ Bipolar & MDD can be given in addition to BED if meet full

criteria for both◦ Borderline PD & BED can be given if meet full criteria for both

Comorbidity *linked to severity of BED not degree of obesity*◦ Most common: bipolar, depressive, & anxiety disorders◦ Less common: substance use disorders

Other Specified Feeding or Eating Other Specified Feeding or Eating Disorder (307.59Disorder (307.59Atypical AN: all criteria met, except that

despite significant weight loss, the individual’s weight is within or above normal limits.

Bulimia Nervosa (of low frequency and/or limited duration)

Binge-Eating Disorder (of low frequency and/or limited duration

Purging Disorder

TreatmentTreatmentEating Disorders requires specific

interventions Training and supervised practice under

the supervision of an eating disorders specialist is necessary for competency in this area.

Must be able to work on an inter-disciplinary treatment team due to the medical and nutritional issues related to these disorders.

Resources available onlineResources available online Eating Disorders Warning Signs

http://achancetoheal.org/eating-disorders/warning-signs/

Differential Diagnosis Tree

Fast Facts about EDs http://www.aedweb.org/About_Eating_Disorders/3645.htm

Eating Disorders Parent Toolkit

Feelings Wheel

Guide to Medical Management of Eating Disorders

Meal Support Manual for Parents/Friends

Parent’s Role in Prevention

Bulimia Nervosa Guide

ResourcesResources Eating Disorders Factsheet APA:

http://www.dsm5.org/Documents/Eating%20Disorders%20Fact%20Sheet.pdf

Eating Disorders Helpline:http://www.anad.org/eating-disorders-get-help/eating-disorders-helpline-email/  Eating Disorder Support Groups by State:http://www.anad.org/eating-disorders-get-help/eating-disorders-support-groups/  Support Groups:http://www.allianceforeatingdisorders.com/Support-Groups  Eating Disorders Anonymous:http://www.eatingdisordersanonymous.org/  EDA Meetings:http://www.eatingdisordersanonymous.org/meetings.html  Mentor Connect: Online mentoring relationships to replace eating disorders:http://www.mentorconnect-ed.org/

Resources Resources Eating Disorder Statistics:

http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/

Eating Disorder Mortality Statistics:

http://www.anad.org/get-information/about-eating-disorders/making-sense-of-ed-mortality-statistics/

  Eating Disorders and Pro Eating Disorder Internet Sites:

http://www.anad.org/get-information/eating-disorders-and-the-internet/

  Righting Insurance Discrimination of Eating Disorders:

http://www.anad.org/get-information/insurance-issues/

  ECRI Institute for Research on Eating Disorder:

https://www.ecri.org/Pages/default.aspx

  National Eating Disorders Association

http://www.nationaleatingdisorders.org/

ResourcesResources Binge Eating Disorder Association:http://bedaonline.com/  Academy for Eating Disorders:http://www.aedweb.org//AM/Template.cfm?Section=Home  The Eating Disorder Foundation:http://www.eatingdisorderfoundation.org/

The Alliance for Eating Disorders Awareness: DSM V Diagnostic Criteria

http://www.allianceforeatingdisorders.com/dsm-bed  Males and Eating Disorders:http://www.allianceforeatingdisorders.com/males-and-eating-disorders  National Association for Males with Eating Disorders, Inc.http://www.namedinc.org/

ResourcesResources Something Fishy: Issues for Men with Eating Disorders:http://www.something-fishy.org/cultural/issuesformen.php

Etiology of Eating Disordershttp://www.allianceforeatingdisorders.com/what-causes-eating-disorders  Suggested Reading on Eating Disorders:http://www.allianceforeatingdisorders.com/help-resources-suggested-readings  Eating Disorders Organizations and Websites:http://www.allianceforeatingdisorders.com/organizations-and-websites   About Face:http://www.about-face.org/

 The Body Positive:http://www.thebodypositive.org/

Body Image Health:http://bodyimagehealth.org/

Resources Resources Becoming Your Most Authentic Self:http://bi3d.tridelta.org/Home  Andrea’s Voice Foundation: Disordered Eating and Related Issues: http://andreasvoice.org/  The Elisa Project: Overcoming Eating Disorders Through Knowledge: http://www.theelisaproject.org/  Families Empowered And Supporting Treatment of Eating Disorders

(FEAST):http://www.feast-ed.org/

Community Outreach Prevention of Eating Disorders:http://www.dahliapartnership.org/  Eating Disorders Coalition:http://www.eatingdisorderscoalition.org/  Eating Disorders Hope:http://www.eatingdisorderhope.com/